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The forensic sexual assault exam is paid for by the state, but sexual assault survivors often pay out-of-pocket additional costs.

Five years ago, Moira Foley was a nurse in New Orleans. She remembers the night a teenager, a rape victim, came into her hospital.

“We had our evidence collection kit, and this poor 16 year old who had been assaulted at Mardi Gras, and we literally had to open the kit and read the instructions,” Foley remembers.

“And as I’m standing there doing it, I’m thinking, ‘this is her evidence – if this goes to trial, it’s us who this is on, and we don’t know what we’re doing.'”

Foley says she decided to get certified to perform sexual assault forensic exams, or SAFE exams. Now, she’s one of nine nurses in Travis County who perform SAFE exams in a small room in the back of the ER.

St. David’s is the only place in Travis County where sexual assault victims can go to get evidence collected 24/7 by a certified Sexual Assault Nurse Examiner.

The state’s Attorney General’s office will reimburse local police for the exam itself, but there are a lot of other costs related to sexual assault that the victim must pay for themselves, including injuries, triage, medical clearance, and medications to prevent pregnancy and sexually transmitted infections.

Plus, rape survivors have to pay just to be admitted into the ER in the first place.

After they leave the Emergency Room, there are more costs: lost work productivity, counseling and legal fees if the case goes to trial. A University of Texas at Austin study from the Institute on Domestic Violence and Assault found these additional costs can total $100,000 per sexual assault. That same study found the average sexual assault exam bill is anywhere from $900 to $1200 per victim.

Foley, a nurse at St. David’s, says when it comes to the stress of getting a forensic exam, “billing is one of the biggest ones. It’s always in the back of everybody’s minds.”

Foley says the nurses sit down with each patient and try to find ways to reduce costs, but sometimes there’s not a lot they can do. Many victims end up going to the local non-profit, SafePlace, for help.

“Survivors are really shocked and surprised when they get these bills,” says SafePlace’s Director of Transitional Services Coni Stogner. “And it’s a pretty sad situation that someone who is already struggling trying to deal with this horrible trauma also has to have this other big hurdle to try and figure out how to get over.”

Stogner and Foley say many women don’t have insurance to pay for these additional costs or don’t want to use their current insurance.

“We might see the college kid who’s not ready to tell her mom and dad about what happened, so she might opt not to involve her insurance so mom and dad don’t find out,” Foley says. “Or maybe they have a high deductible, they know they’re not going to come close to that.”

The victim might also share insurance with their attacker – a spouse or partner – and doesn’t want them knowing they’ve had the exam. But if a victim wants the exam done by a trained nurse, which is key if a victim wants evidence collected to be used in a trial, St. David’s is their only nearby option.

“This exam could be done somewhere that is not an emergency room, so then these costs would never be incurred in the first place,” Stogner says. “I think community partners in Travis County, including St. David’s, really recognize the need for an exam site outside of a hospital system where victims who aren’t in need of that emergency care could receive the medical exam and medications free of charge.”

SafePlace is planning to open a 24-hour clinic staffed by certified nurses to perform SAFE exams on women and men who do not have additional medical needs.

“Our ERs do an amazing job, but they’re busy and I think even they’d appreciate you don’t want someone to enter the hospital system if they don’t need those services,” Stogner says. “There’s certainly attention to preventative care in a lot of ways and having folks not end up in an ER when they don’t need those services would be helpful for everyone.”

Foley wouldn’t speak directly about SafePlace’s plan, but she says there are some benefits to have the exam done at an emergency room.

“Sometimes you don’t find problems until you’re in the middle of the exam,” she says. “I’ve had that happen quite a few times. Genital injures, severe genital trauma that may need intervention there.”

Foley says patients might not reveal details of the attack that health care providers aren’t aware of until later.

“A patient… didn’t disclose to the ER physician that they were choked to the point of passing out,” she says. “When we’re sitting in here spending a few hours with them, they’re sitting here acting groggy, and we’ll realize, ‘wait, this needs to be look at further by an ER staff.’”

SafePlace says 96 percent of sexual assault survivors do not need additional medical care, according to an article from 1997.

Nurses at St. David’s disagree. Out of the 96 patients they’ve seen so far this year, 65 have needed additional medical care, everything from alcohol withdrawal and cardiac care, to additional medications for injuries.